What You Need to Know About Surprise Medical Billing
Here’s something you can look forward to this year: an end to unexpected, or “surprise,” medical bills. That’s thanks to the new federal No Surprises Act, which took effect January 1, 2022.
“Many people reasonably assume that they won’t get billed by some random provider they had no role in choosing. So they may not even appreciate this new law,” says Loren Adler, an associate director of the USC–Brookings Schaeffer Initiative for Health Policy. “But those who have been affected by surprise billing will understand what a huge deal the No Surprises Act is.”
What is surprise medical billing?
Surprise medical billing, also known as balance billing, happens when you unknowingly receive care from a provider or facility that’s outside of your health insurance network. For instance, an out-of-network specialist might treat you at a hospital emergency room. Or you could choose an in-network orthopedist to repair your rotator cuff, but the anesthesiologist on duty may not participate in your plan.
Instead of accepting a discounted, in-network rate, out-of-network providers have been allowed to bill for the “balance” between what insurance pays and the amount they charge “retail.”
How common is surprise medical billing?
It’s been a common practice: 1 in 6 Americans polled in 2020 said they or someone in their family had received a surprise medical bill within the past two years, according to the Kaiser Family Foundation (KFF).
What does the No Surprises Act do—and not do?
Dozens of states have passed laws to curb surprise medical billing or balance billing. The federal No Surprises Act helps to protect you regardless of where you live or how you get your insurance. This is important because large employers often self-fund their health insurance plans and are subject to federal but not state regulations.
The No Surprises Act is a game changer for people with private health insurance. (Exceptions may include short-term insurance plans with low premiums.) But that doesn’t mean all risk is off the table. Here, find out what’s new and what you still need to watch out for.
- Most emergency room care will essentially be considered in network. “You will still be responsible for copays and deductibles, but you will no longer have to worry about being taken to a hospital that participates in your plan,” says Caitlin Donovan. She’s a senior public relations director at the National Patient Advocate Foundation.
- Transitional care is covered. Let’s say you get taken to an out-of-network ER and then you’re admitted after emergency treatment. Your care will be billed as in network until your condition is stable enough that you can be transferred.
- Any care at in-network facilities must be billed at in-network rates. A common scenario for surprise billing happens when you schedule a procedure at an in-network facility, then months later, you get a bill for a care provider you had no control over—the anesthesiologist who was part of the surgical team or the pathologist who assessed your lab results—at pricey out-of-network rates. No more.
The new law requires that providers who participate in non-emergency treatments at a facility in your network must be billed at in-network prices whether they’re individually on your plan’s in-network list or not. (Unless you sign a waiver, which we’ll talk about next.)
- You’ll know ahead of time if you’ll be billed for out-of-network care. As a patient, you may still want to see your beloved out-of-network gynecologist or consult a non-participating specialist for a complex condition such as cancer. The new law won’t stop you.
It will, however, require out-of-network providers to send you a waiver to sign at least 72 hours in advance of your appointment if they plan to balance-bill you. On top of asking for written consent, providers must give you a rough estimate of what out-of-network costs might be and include a list of alternative in-network providers at the same facility.
- Air ambulance trips are billed as though they’re in network. A 2020 survey from The Milbank Quarterly found that 2 in 5 emergency air transports in the U.S. resulted in a “potential balance bill” averaging $19,851.
That’s because an enormous number of these calls—about 70%—are answered by out-of-network providers who charge privately insured patients a median rate ranging from $36,400 to $40,600 per trip, according to a recent congressional report. Under the new law, you would have to pay only the deductible and copayment amounts you would for in-network transport.
- Providers won’t be allowed to send you a bill for above-network rates of covered services. Key wording in the new law is “shall not bill”—meaning doctors, labs, and facilities are prohibited from even trying to send balance bills after treating you at in-network rates. That means less risk that you’ll pay by mistake and have to request (and wait for) a refund when and if you notice you’ve been wrongly charged. Violators can be fined up to $10,000 for each offense.
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What You Still Need to Watch
Ground ambulance services
More than half of all emergency ground ambulance rides result in an out-of-network bill, according to a joint 2021 Peterson Center on Healthcare/KFF report. Yet ground ambulance transport was left out of the No Surprises Act.
“There was really no good reason the issue was omitted other than that lawmakers were already struggling to pass the bill, and ground transport [provided by a mix of local governments, volunteer squads, and private companies] was just too complicated to take on,” says Adler.
A commission has been formed to study the issue, but in the meantime, “you can’t really do much to avoid getting an ambulance that’s out of network during an emergency, since dispatchers choose the ambulance,” Donovan says.
What you can do:
- In non-emergency situations—for example, when being transferred by ambulance from one hospital to another—ask the facility if there’s an in-network service you can use.
- If you do get a surprise bill for ground ambulance transport, ask your insurer to review it., The insurer may increase the amount that’s covered. Also ask the ambulance service directly to adjust its fee.
- The No Surprises Act is federal legislation, but 33 states and Washington D.C. also have laws that curb balance billing—and yours might include restrictions on ground ambulance charges. Emphasis on “might,” so find out legislation is where you live. One wrinkle: If your employer’s insurance plan is self-funded, it’s covered by federal law, and abiding by state regulations is voluntary. A call to HR or your company’s benefits department is a first step in helping you sort out your options in that case.
Yes, urgent care clinics often provide what you might think of as emergency care (x-rays for a twisted ankle, stitches for a nasty cut). So the new law’s prohibition on balance billing at hospital and medical center emergency rooms doesn’t explicitly address how billing should be handled at other urgent care facilities.
“The vague language around urgent care facilities could leave you vulnerable to a balance bill if you go to a clinic that isn’t in your network,” says Donovan.
What you can do: Before there’s an urgent situation, make some calls and find out which nearby clinic accepts your insurance. However, “if you think you have a problem that’s serious enough for an emergency room, you should probably be going to an actual ER, unless there isn’t one anywhere near you,” Donovan points out.
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Erroneous billing and misinformation
Simply because there’s a new law in effect doesn’t mean every doctor’s office and medical facility will comply—whether by choice or by oversight. Stay vigilant and go over bills and insurance paperwork carefully.
“Consider it a red flag if you receive a bill that isn’t in the Explanation of Benefits you get from your insurer, if you get a bill from an out-of-network provider, or even if a charge is different from the cost-sharing amount you’re supposed to pay,” Donovan says.
What you can do:
- First, call your insurer, who should be able to explain the charges you’re seeing. If a charge does turn out to be wrong, your next call should be to your provider. “Honest mistakes are possible. But if you get pushback, stand firm.” says Donovan. If you can’t resolve the problem, call the federal hotline, which is being set up as part of the No Surprises Act.
- Hold your insurer accountable. Ever called a doctor listed in your insurance directory and been told the doctor dropped your plan? Now the onus is on insurers to keep their information up to date. “If you find a provider in your plan’s directory, take a screenshot of the listing. Under the No Surprises Act, if a non-participating provider is still listed in their directory, your insurer will have to cover their charges,” Donovan says.